Provider Demographics
NPI:1962734442
Name:IRVIN, STEPHEN BROOKS (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BROOKS
Last Name:IRVIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7386
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27109-6233
Mailing Address - Country:US
Mailing Address - Phone:336-758-5218
Mailing Address - Fax:
Practice Address - Street 1:1834 WAKE FOREST RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27109-6000
Practice Address - Country:US
Practice Address - Phone:336-758-5218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02196363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical